OP0082 DISCORDANCE BETWEEN DAS28ESR AND PRESENCE OF ULTRASOUND POWER DOPPLER DURING EARLY TREATMENT IS ASSOCIATED WITH DISTINCT CLINICAL AND IMAGING PHENOTYPES AT PRESENTATION
Authors: R. Shukla, R. Wakefield, P. Emery, D. Plant, M. H. Buch
Journal: Annals of the Rheumatic Diseases (2022)

Background Discordance between DAS28ESR and musculoskeletal ultrasound (MSUS) detected power Doppler synovitis (PDUS) is well-recognised and may lead to under/overtreatment. We hypothesize that clinical and imaging features at diagnosis associate with early discordance of DAS28-PDUS and change in DAS28-PDUS status following DMARD treatment. Objectives To identify pre-treatment clinical factors associated with discordance and change in DAS28-PDUS status during early treatment in an early RA trial cohort. Methods The ‘VEDERA’ trial 1 randomised 120 treatment-naïve, new-onset RA patients to either first-line etanercept + methotrexate (ETN+MTX) or methotrexate treat-to-target (MTX-TT) regime with escalation to ETN+MTX if not in DAS28ESR remission at week 24. Clinical and MSUS assessments were completed at baseline, weeks 12, 24 and 48. DAS28ESR ≤ 2.6 and DAS28ESR &gt; 2.6 categorised remission and active disease respectively. PDUS presence was defined as total PDUS score ≥ 1. Active concordance (AC) was defined as active disease with PDUS while active discordance (AD) was defined as active disease without PDUS. Remission concordance (RC) was defined as DAS28ESR remission without PDUS while remission discordance (RD) was defined as DAS28ESR remission with PDUS. Bayesian multinomial logistic regression (posterior estimate and 95% credible intervals reported) was used to address the study objectives with AC as the comparator group. Results At baseline all patients had active disease (moderate or high DAS28ESR) in line with trial eligibility - 68% (81/120) were AC and 32% (39/120) were AD. Compared to AD patients, AC patients were older (median age 53 vs 44), had higher DAS28ESR (5.90 vs 5.16) and CRP (11.6mg/L vs 3.6mg/L), as well as a higher presence of greyscale (GS - 100% vs 67%), power Doppler tenosynovitis (PDTS - 78% vs 49%) and erosions (20% vs 0) (p &lt; 0.01). Figure 1 illustrates the pre-treatment proportions and change in group proportions at each timepoint, revealing an early shift of AC to AD (36% by week 12) or RC (22% by week 12) but persistence of those in AD from baseline at subsequent timepoints (64% at week 12). Baseline characteristics associated with each group compared to the comparator AC group (at weeks 12, 24 and 48) are reported in Table 1. For AD versus AC these were lower CRP at week 12 and female sex at week 24. For RC versus AC these were lower CRP and allocation to ETN+MTX at week 12, allocation to ETN+MTX and presence of PDTS at week 24 and younger age at week 48. For RD versus AC these were presence of PDTS at week 24 and male sex at week 48. Table 1. Baseline characteristics associated with longitudinal discordance vs concordance. AC is the comparator group. Results in posterior estimate with 95% credible intervals Week 12 Week 24 Week 48 AD vs AC Female 0.53 (-0.44 to 1.48) 1.52 (0.51 to 2.59 ) 0.17(-0.91 to 1.25) CRP -0.05 (-0.1 to -0.01 ) -0.01 (-0.04 to 0.05) 0.01(-0.02 to 0.02) RC vs AC Age at diagnosis -0.04(-0.09 to 0.01) -0.02(-0.06 to 0.03) -0.08(-0.13 to -0.03 ) CRP -0.05 (-0.10 to -0.01 ) 0.001(-0.04 to 0.03) 0.01(-0.02 to 0.04) ETN+MTX 1.57, (0.57 to 2.64 ) 1.26, (0.29 to 2.33 ) 0.91(-0.02 to 1.85) PDTS 0.58 (-0.5 to 1.68) 1.23(0.2 to 2.29 ) 0.8 (-0.2 to 1.83) RD vs AC Female 0.23 (-1.26 to 1.72) 0.9 (-0.41 to 2.26) -1.59(-2.9 to -0.35 ) PDTS 1.00 (-0.55 to 2.69) 1.79 (0.44 to 3.33 ) 0.95(-0.29 to 2.27) Conclusion DAS28ESR and PDUS discordance and concordance have distinct clinical and imaging phenotypes at presentation. Baseline active concordance and discordance respond differently to treatment –a sizeable proportion of former transition into active discordance early on and the latter persist in the face of effective treatment. Understanding the basis for these phenotypes is essential to facilitate optimal aggressive treatment and/or alternative management strategies. References [1]Emery P, Horton S, Dumitru RB, et al. Pragmatic randomised controlled trial of very early etanercept and MTX versus MTX with delayed etanercept in RA: The VEDERA trial. Ann Rheum Dis. 2020;79(4):464–71. Disclosure of Interests None declared.